Healthcare Provider Details

I. General information

NPI: 1639259641
Provider Name (Legal Business Name): GREGG M. MENAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9977 WOODS DR 3RD FLOOR
SKOKIE IL
60077-1057
US

IV. Provider business mailing address

2650 RIDGE AVE EVANSTON HOSPITAL
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-663-8062
  • Fax: 847-663-1027
Mailing address:
  • Phone: 847-570-1644
  • Fax: 847-733-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036103610
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: